Non-Eng Med. Hist.
4 – Form AOHHF1© Are You Multi-Lingual?
ARE YOU MULTI-LINGUAL?
DO You Have Family and Friends Who Are Not And Do Not Speak English?
Are You Willing To Protect Them With Information That Can Save Their Life in an Emergency?
Ask Here For A Medical History Form That You Can Fill Out For Them, And They Can Carry in Case They Need Medical Care When Alone.
Thank You!
6 – Form AOHHF3©
Start Copy and Paste Below The Dotted Line
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English Medical History Form For Non-English Speakers
English Medical History for (Name)________________________________ Who Speaks Only (Language) ____________________________
Created by __________________________On______________________Tel.________________________
My Medical Information (Make One for Each Family Member & Keep It with You for Emergencies)
Name ______________________________________________________ Phone#_____________________________________________________
Birthdate____________________________________________________ Birthplace___________________________________________________
Address________________________________________________________________ City_______________________ State__________ Zip________________________________
Emergency contact – Name ________________________________________________ Phone _______________________Relation_______________________
Primary Care Physician – Name __________________________ Phone______________ Specialist Physician – Name _____________________________ Phone_____________
Specialist Physician – Name _____________________________ Phone_____________ First Hospital Choice – _________________________________________________________
My History – Surgery or Medical Condition Dates
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Diabetic?____Yes ____No
My Diagnoses, Medications & Dosages __________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
I am allergic to: _________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________
Blood Type __________________________________________________ Insurance Co. _______________________________________________ Phone________________
Policy Group____________________________________________ ID#________________________________
Other Important Information ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Other Contacts –
Name ____________________________________________________________Language________________ Phone ___________________________Relation____________________________________
Name ____________________________________________________________Language________________ Phone ___________________________ Relation____________________________
Based On the Writings of Rev. Mike Wanner who channels the Angel Of Healing – Raphael – Rev. Mike Wanner * mikewann@voicenet.com * www.AngelRaphaelSpeaks.com
Compliments of________________________________________________________